BH13 Is this dissecting cellulitis of the scalp in a White child?

Abstract

Abstract Dissecting cellulitis of the scalp (DCS) is characterized by recurrent pustules and sinus tract formation leading to scarring and alopecia. Follicular obstruction is a key pathogenic event and is associated with hidradenitis suppurativa and acne conglobate. Commonly, DCS is found in adult men of Afro-Caribbean descent (Arneja J, Vashi C, Gursel E, Lelli J. Management of fulminant dissecting cellulitis of the scalp in the pediatric population: case report and literature review. Can J Plast Surg 2007; 15:211–14). We describe a rare case of a White child who presented with features suggestive of DCS. An 11-year-old boy was referred with a 2-year history of patches of alopecia affecting the occipital scalp which was initially treated as tinea capitis with antifungal creams, but this was ineffective. On examination, there was diffuse, boggy subcutaneous swelling with scarring, overlying erythema and patches of alopecia on the occipital scalp. A course of erythromycin and oral terbinafine showed a partial response of the affected areas, although subsequent new patches of alopecia were noted with a similar manifestation of bogginess and overlying erythema. Systemic examination, blood tests and skin scrapings were unremarkable. While continuing erythromycin, he was counselled for isotretinoin and a referral to a tertiary centre has been made to guide further management. Paediatric scarring alopecia encompasses congenital and acquired causes (Imhof R, Cantwell H, Proffer S et al. The spectrum of pediatric scarring alopecia: a retrospective review of 27 patients seen at Mayo Clinic. Pediatr Dermatol 2021; 38:580–4). The differential diagnosis for our patient included tinea capitis causing irreversible alopecia, and being aware of this phenomenon with late presentations and delayed treatment is vital. Other differentials are discoid lupus and cutaneous morphoea. However, the clinical features in this case are more in keeping with DCS, which is scarcely reported in the paediatric literature. Histological confirmation is not always practical with children, and follow-up to assess course of the disease is prudent. Importantly, the discussion of permanent hair loss with a child and parent remains challenging, and clinicians should be aware of the associated psychosocial impact.